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Download LMC model, Hepatitis B - League of Minnesota Cities
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Transcript
Hepatitis B Vaccination Declination Form I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. I have read this form and understand its contents. Employee’s initials: ______________ Employee Printed Name Employee Signature Date Witness Printed Name Witness Signature Date League of Minnesota Cities Potential Infectious Disease Exposures in Municipal Operations 4/4/2016
